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Hi, everyone. Thanks for coming. Um Can someone just pop in the chart that they can hear me? Um And if you've not come to any of Co Blue's um talks before then what's gonna happen is there's gonna be 40 minutes of teaching followed by Otey Practice and we're gonna split off into breakout rooms. I do highly recommend staying for the OSC practice. It's really, it's really good um sort of consolidate what you've learned in the teaching. Um So if anyone has any questions, I'll be monitoring the chat um throughout the session. Um And I'll hand it over to Isaac. Ok. Thank you. So, today we're gonna be discussing how you manage an acutely unwell patient with particular folks on how you do this during your oy. So these are our partners. Uh If you're interested, there's some codes, you can get the slides. Um If you fill out the feedback form at the end, just making sure everyone can hear. Cos Siobhan is putting the chat and we haven't got a response yet. Ok. Mixed response. We've got a no and a yes. Well, anyone else give us an idea if they can hear. Ok, excellent. So it looks like a few people can hear. OK. So the objectives of this is just uh recalling a structured approach to a history, recognizing important red flag symptoms, generating differentials based on the history and going through some of the common conditions that are associated with being acutely unwell, we'll discuss a structured approach to examining acutely unwell patients. And then finally, we'll have a quick go prescription task if there's time. So by now, you should all be pretty familiar with how you take your history. Um So we're not gonna spend long discussing this, but and you'll get a chance to practice this in the osk stations after, but just to quickly go over, we've got our presenting complaint. Some people may choose to use Socrates here. This just gives you a bit more information about what's been going on. You got the history of the presenting complaint. It's all about gathering your timeline, making sure you're clear and your onset, your duration, the progression um considering a systems review and red flags is really important in your oss and is as is ice. Ice is usually there's always a few marks in your OSC for getting it and they're quite easy marks. So it's important not to forget other than that past medical history, surgical history, medication history, family history and social history. Just will wrap up your histories nicely. So importantly, I've just put some symptoms that you might consider thinking about in a systems review or uh these also are red flag symptoms. Quite a lot of them like chest pain, shortness of breath and rest abdominal pain, hematemesis and Melina, which we'll talk about a bit genitourinary symptoms. We're not gonna discuss much of in this um presentation. There's a few more here. Ok. So now we're gonna recall some of the common conditions associated with being acutely unwell. The first one is acute kidney injury. All this is is a rapid decline in kidney function. It's very common. So it occurs in about 20% of all hospital admissions. We diagnose it through a rise in serum creatinine or a decrease in urine output for the kidney to function. There's three things, it requires adequate blood flow, functioning, nephrons and a clear urinary outflow. There's any alterations within the system, an acute kidney injury can occur. So, in a KS, the kidneys stop functioning as well. And then complications arise. These include fluid overload, electrolyte derangement, particularly hyperkalaemia. So, raising potassium uremia and in some cases, potentially death. So when we talk about AK I, it's important, we think about the causes and these are divided into prerenal renal and postrenal prerenal causes about 85% of ATI S. So this is the most common cause results from just a reduced perfusion of the kidneys. That's either hypovolemia, a reduced renal blood flow or sometimes a reduced cardiac output. So, some of the prerenal causes we've got here. Hypovolemia So you'll see that in bleeding or vomiting and diarrhea, low effective arterial blood volume. So, this is the third spacing of the f the fluid that you might find in sepsis or heart failure. There can be anatomical causes of prerenal like renal artery stenosis. And really importantly in A Kr AKR is the medications. So, nsaids, ace inhibitors, diuretics and uh uh antibiotics at the top here, like gentamicin and Streptomycin. These are really important to think about as well as prerenal causes or renal or intrinsic causes, which occur from like structural damage to the kidney. This occurs in as we've got here, acute tubular necrosis, acute interstitial nephritis and glomerular diseases. Finally, post renal or these are also called obstructive causes, just cause an increase in pressure within the kidney and they decrease the G fr. So these can be divided based on where the obstruction is anatomically located. And we've got a few examples at the bottom of it. So, the purpose of this lies just to think about the causes and break them up into three. And also to mention medications that's always important to think about in a. So these are some risk factors for acute kidney injury, sepsis. Over 65 kidney disease, heart failure, diabetes, liver disease, cognitive impairment. Uh This is just because they're less likely to remain hydrated. If we remember, the prerenal dehydration is the most common cause of AK I medications we discussed in the previous slide and radiocontrast agents. So you need to be careful if you're thinking about certain CT uh investigations in people with AK I or any kidney disease? Ok. So symptoms and signs of AK I firstly, you must suspect and screen for AK I in all acutely unwell patients is frequently asymptomatic or it's very nonspecific. So they might just be fatigued. Have a bit of nausea or confused but reduced urine output is a key feature. Hypovolemic features. Does anyone know any examination findings that you might find on a hypovolemic patient? Just pop it in the chart. If anyone can think of anything you might find. No. Ok. So hypovolemic features is just things like a dry mucous membrane. You might find that the patients are tachycardic and hypotensive and may also have sort of reduced skin tone. What about volume overload features? Can anyone put that in the chat? Any ideas of what you might find on examination? Someone that's overloaded, edema? Yup. Very good. So that can either be on the lungs. It can be peripherally. You also might find a raised JVP and the BP might be raised in volume overload in uh acute kidney injury if it's bad and they become uremic features of that are quite neurological. So they can be confusion, seizures, sometimes signs of pericarditis which would be a pericardial rub. You'd hear an auscultation and chest pain. They also may experience bruising and arrhythmias. Ok. So a red flags just to watch out for in AK I oliguria, edema, arrhythmias, confusion and neurological symptoms, persistent vomiting and diarrhea just because they've become hypovolemic, any evidence of hypotension or any signs of sepsis and fevers. So, AKI stagings 12 and three, it seems fairly complicated. It's not really if you break it down into stage one is just a rising creatin between 1.5 and two times. Baseline. Stage two is 2 to 3. Stage three is just above three. That's the way I remember it. Ok. So, investigations and management, you've gotta dip the urine first and then you'd consider your blood test. So this might be FBC S using these LFT SV VG on your V VG. Um You may find electrolyte abnormalities like the hyperkalemia. Some cases you'd need to consider imaging as well. So act or an ultrasound might be appropriate and there's an, a three checklist to make sure you remember everything when managing uh AK is. So you're addressing the drugs, stopping the nephrotoxin that we talked about. You're boosting your BP. So you're thinking about your fluids, you're calculating a fluid balance here. You might even consider catheterizing the patient. You're dip in the urine and you're excluding obstruction, severe cases may require sort of dialysis and specialist input from the renal physicians. Um And that's if the sort of features are refractory to medical management. So, despite medical management, they might still have high potassium pulmonary edema or any sort of uremic features like the pericarditis or the enkephalin. So commonly associated associated with AC as we discussed, this sort of de dehydration. Um this will present as on blood results as an increase in urea to creatinine ratio. This is quite important because it just comes up quite a lot in MC QS and in data interpretation during your OS. So if you notice there's an increase in urea to creatine ratio, creatinine, Sorry, then you're thinking that the cause of this at is probably dehydration of prerenal. Ok. So we did briefly talk about, can anyone think about some signs of dehydration on clinical examination? What they might be? Yeah, that's a fair point. Thank you, Adrian sunken orbits. Obviously, they might be thirsty. That's a easy one. They might have just be dry, might have reduced urine output. They might be a bit tired or dizzy or confused. They might have reduced skin Zurg. And as you said, they might have a fast heart rate and a low BP here managing is just based on uh addressing the underlying cause of the dehydration and rehydrating with fluid. So, sepsis, I'm just gonna quickly go over as well. So this is a life threatening organ dysfunction just caused by dysregulated ho host response. What that means is just an exaggerated immune response to the infection. Septic shock is uh sepsis with hypertension. It's not responsive to fluid resuscitation. It's often accompanied by signs of organ dysfunction one that you might see on a V VG or ABG is a raised lactate. Septic shock is uh associated with an increase in mortality. So, a common source of infection and sepsis include pneumonias, UTIs, skin, soft tissue and joints and indwelling devices. Got a few risk factors here. That's also important to consider. So how does sepsis present? It's often dependent on the source of infection. So, if it's urinary, they might have pain on passing urine. If there's a chest infection, they might have a cough if there's gi s diarrhea. So it's really important during A OSC, you sort of work out if there's any sort of preceding illness before they've presented very unwell to you and also frequently the symptoms are very nonspecific. So you just get might, might get fever, tiredness, uh muscle pain, skin changes. But generally the features we look out for in sepsis is fever, tachycardia, hypertension confusion, my stenosis there, tachypneic and a few other things. But fever, tachycardia, hypotension, confusion and tachy tachypneic are the most important to look out for new schools, consider lots of these features and they're quite useful uh in sort of indicating the severity of an unwell patient. Ok. So does anyone know what the sepsis sixth? Is anyone outline that for us? She got take six by Mohammed. Give three, take three. Yeah, exactly. Give through, take through. Does anyone know what we're giving and taking? Ok. Yeah, very good. So you guys have both given us what we give and Julian's just come through and giving us what we take. So yeah, it's important I think to start with taking. So we need to take our blood cultures before we give the antibiotics. We need to have a look at that lactate through our V VG or ABG. And uh think about measuring the urine output. Here, you can do that via catheter or just via fluid chart. And then we give three like you've all said correctly, oxygen if it's required antibiotics. The answer usually is always follow local guidelines, but often you start a broad spectrum antibiotic like tazocin in these circumstances and then think about fluids. So, fluids is quite important in here. Does anyone know what resuscitation fluids usually are? What we usually give to a patient? This hypotensive in this situation, Hartman's is a good suggestion. Yeah, Hartman's or Saline is usually given, you usually give a 500 mL bolus in less than 15 minutes. Ok. So also there are some additional investigations that you might consider including sort of sputum urine cultures, swabs chest x-rays bloods. This is important for when you're trying to identify the source of infection. So you can narrow down your treatments. Um importantly, also is looking at clotting screens and coagulation studies which brings us on to D IC sepsis is commonly associated with the IC and it's just dysregulation of coagulation. That's a bit of Mle, but it causes clotting and bleeding. It also occurs in some trauma malignancy and some obstetric complications. Most obviously, what you'll see on bloods is a decrease in platelets and a prolonged, a prolonged PT and A PTT. Um So it's really important just to recognize here that you see the thrombocytopenia and the prolonged PT and A PTT. Um The management is also just based on under uh treating the underlying cause and then a bit of supportive uh therapy. So, replacing any blood products, if it's required this table here uh shows typical blood results of what we might see in a, a septic patient that's a bit dehydrated. They've got an acute injury and they also have D IC. So everything we've just discussed, so we can see the white white cells here which suggesting infection, a low platelet with a prolonged PT and A PTT suggests D IC an increase in potassium may be seen in the AK I. The increase in urea to creatinine ratio suggests dehydration and gives us more evidence towards the prerenal AK I, we've got reduced eg FR which also suggests AK and A raised CRP which we see in infection and inflammation. Ok. So upper gi bleeds, these are a common medical emergency common in exams. It's just blood loss from the gi tract that's proximal to the duodenojejunum. And this just involves bleeding from the esophagus stomach or duodenum and the mortality is quite high. So it's really important. We look out for these. The cause is most commonly in the UK. It's caused by a peptic ulcer. Uh, with this, there might sort of be an associated history of excess NSAID use. So when you're doing a gi bleed history, you might want to ask about nsaids, it also can be caused by a mallory waste, which it's a tear of tissue in the esophagus, just usually caused by violent coughing or lots of vomiting. So, therefore, it is associated with binge drinking and gastroenteritis just because they're vomiting a lot. Esophageal viruses associate with liver disease because you get these dilated veins in the esophagus from uh portal hypertension. It increases the pressure in these veins and it just makes them susceptible to bleeding and also certain malignancies in the gi tract like stomach cancer can cause these bleeds. So important things to look out for in your history. Most of these symptoms actually are, are red flags as well. So someone comes in with hematemesis, that's just vomit with blood in. What sort of things would you like to know if someone tells you I've been vomiting blood. Can anyone give me any ideas? Yeah. Both very reasonable suggestions. Thinking about. When did it start? What's the volume? How much, uh, are they being sick? How much blood is in it? What's the, are they still vomiting blood? Is there anything that's triggered it? Have they ever had this before? You also might get coffee ground or fresh red vomit or Melena, which is just black tarry store from an apple G IV. If you hear about Melena, they might have a slightly more chronic history than the sort of fresh hemostasis, epigastric pains. Also, in a feature, you need to ask them about an anemic symptoms such as dizziness, shortness of breath and syncope, ok. Uh change in bowel habit. So blood is actually an irritant to the GI system. So it can cause a bit of diarrhea. So it's worth asking about uh the symptoms and signs will obviously vary depending on the size and severity of the bleed. But once you've asked them about their symptoms, you don't think about asking about cause causes of the bleed. So NSAID use liver disease things we've just discussed. Obviously, hemodynamic instability will be quite a concerning feature here. So there are two scoring systems that are important to remember for exams in an upper gi bleed. Firstly, is the Glasgow Blatchford bleeding score. You do this before an endoscopy and it's just used to sort of stratify which patients are low risk and actually can be managed as a outpatient. A Rockall score is used after endoscopy, which is to determine the severity of the bleed and the risk of rebleeding. So how do we investigate and manage up gi bleeds? So a beat is a mnemonic you can use to remember. So you need to take an A two E approach to resuscitation. Um We're about to discuss this in more detail. But bloods can anyone suggest what bloods you might want to request in a a gi bleed? Yeah, FBC reasonable. It might be a bit anemic user knees. You can see a raised urea in an upper gi bleed LFT S coagulations group and save cross matches. And you might think about requesting two units of blood straight away. Here. You also need access. You need two large cannulas transfusions such that they need blood endoscopy, uh or should have an endoscopy within 24 hours and then drugs, you need to think about stopping maybe some of their medications. What medications might you think about stopping in an up? I believe. Nsaids. Yeah. NSAID S and anticoagulants. That's the big two and in a significant hemorrhage you might need to. Yeah, exactly. And set some anticoagulants, um, in a significant hemorrhage, you might need to activate the major hemorrhage protocol. In most hospitals you're calling 2222. It's stating major hemorrhage in your location and it just allows a rapid and appropriate response and you immediately get four units about negative blood. Ok. This is just what we suggest that you might see on the blood and what drugs to start. Ok. So variceal management is slightly different. The resuscitation process that we just discussed is sort of the same, but they also require tele breathin, which is a vaso um, constrictor increases vascular resistance, reduces cardiac output and actually reduces the portal pressures by about 20%. You also need to give prophylactic antibiotics. This is usually IV cefTRIAXone, but um importantly, follow your local guidelines. And then these are just various endoscopic techniques that might be used but not so important to you right now. So the a to approach, this structured approach is a way of assessing acute unwell patients as a junior doctor and in your exams, um an acutely unwell patient is just someone that's unsta has unstable observations or a reduced G CS. So as we go through your A three, we address the problems as we identify them and then we reassess them and regularly monitor their response to the treatment we've given them. And within each section includes a clinical assessment investigations and interventions. If a patient does lose consciousness and there are no signs of life, then you just need to put out a crash call and start CPR and sort of be a less algorithm. Instead, it's also important to sort of call for help early when there's an acutely well patient. And this is best sort of handed over using the sbar for that. I'm sure you're all aware of right now. So we know how we might assess the airway the first in our a reassessment. Ok. So the first thing to do, uh when assessing the airways, can the patient talk if they can talk then, yeah, they're maintaining their own airway. Um If they can't, you need to think about. Is there an obstruction, is there any airway compromise? Can you see any cyanosis or angioedema? You're listening for noises, stridor and snoring and you're feeling for airflow in the nose and mouth. Adrian suggested some good management options we've got with airway and one of that is jaw thrust and chin, left head tilt, chin lift and uh jaw thrust. So, yeah, what you need to do if there is any signs of airway obstruction or compromise, you call the crash team and or an anesthetist to get help straight away if you can visualize a foreign body. So it's something obstructing the airway, you can attempt to move it with a finger sweep, um or suction, but you should never go in blind because you do actually risk further obstructing the airway. Simple airway maneuvers like Adrian suggested are very good oropharyngeal airways or nasopharyngeal airways might also help maintain the airways. And if the G CS is lessen eight, you might consider intubation here. You need to think is there a reversible cause of airway obstruction that we can fix? So, if this is anaphylaxis, we give adrenaline if there's secretions, blood or vomit that we need to suction. Ok. Moving on to breathing. How do we assess breathing? How do we assess this on his breathing? Well, has anyone got any ideas? Chest movement? Yeah. So you can see it. That's true. Ok. So some more, slightly more objective measurement, perhaps you can get a SAS probe on and look at their pulse oximetry. You can look at their respiratory rate. You might do a brief chest examination, looking for sinois tracheal deviation, chest expansion, think about percussing and auscultating. Some investigations you can do during your breathing assessment. You might consider an ABG to have a look at the oxygen and CO2 levels and also a chest X ray. How do we manage if someone is desaturating and they're not breathing very well, we give them oxygen. Yeah, it's usually 15 L via non reb rebreathe mask in any emergency situation. Um And that answer will almost always be right in an emergency situation. You think about, do they need ventilation or is there anything we can treat sort of the cause of the breathing problem? So, is there a attention pneumothorax here, we can treat it with a needle decompression if they're not breathing because they've had too many opiates. Can we give them a reversal of that? Like naloxone a circulation? How might we assess ac circulation? Trying to assess how well the body is being fused? Central sinois. Yup, definitely capillary, refill time, carotid pulse. Very good. Yeah. So we think about capillary, refill time, peripherally and centrally heart rate, BP. Yeah, that's correct fluid status. So do they need a catheter, fluid monitoring? And then investigations we can think about here are sort of blood tests and E CG or cardiac monitoring. And what are we gonna do in the circulation part. We're gonna need two large bore cannulas in either arm. So we're just gaining IV access here so that we can give either fluids or blood. If there's large blood loss, you might need to consider about activating a massive blood loss protocol. What can help with sort of venous return is if you lay them flat and lift up their legs just helps the blood get back to the heart. So, disability, what might we look for here? Does anyone know what are we assessing? Yeah, AU AU or G CS can be used both indicators, blood glucose. Thank you very much for saying that. And pupils, that's what the de FG don't ever forget glucose and ketones. Um also consider a temperature. GC SA has been said pupils have been said, think about pain. Do they need a CT head? Um ABDO exam. Yeah, some people might consider doing an abdominal exam here. Um But it's also put in the next DNE is sometimes cross over some people put temperature in the E section as well. So I don't think it's a massive deal. Anyway, what can we do? We correct the glucose? We give any sort of pain relief and we look to see if we can treat the cause. Why do they ever reduce G CS? Is there something we can do about that? Now moving on to the everything else and exposure. It's a bit more of a boring one. But we're just fully exposing the patient whilst maintaining their dignity. We're looking for bleeds, rashes, injuries, drains, output sort of lines, any sort of evidence of infection or injury. And then some people here with the examining the relevant system, so it may be abdominal examination or neurological examination and you just manage findings as appropriate. So after you've done your A two E, you've made all your adjustments, you're gonna go back again through it, you go through it a few times, making sure you're monitoring the response to treatment and then you need to find out what's caused this patient to become acutely unwell. Um So you will review the notes, you take a more detailed history. A boxes structure is I've seen used in Ay. So all this is is to make sure you haven't forgotten anything. Boxes stands for bloods or cyst tests, X rays, ECG S and special tests. It's just to make sure you haven't uh missed anything. So at the end, you could just run through that in your head and think. Have I done everything that I need to do here? You will inform and request help from a senior. It's likely that you will have already done this throughout your A two E and you document, you review the results as ne necessary. So here I've just put uh sort of a to ease of what we might expect to find in the different common conditions we talked about earlier So an AK IM OA that's maintaining their own airway. Most people with an AK will be maintaining their own airway. It might, they may not be if they have sort of a decreased G CS and they were very uu uremic. But you hope that this is all right. In an A kr, they may have breathing problems. So they might be tach tachypneic. If there's metabolic acidosis, it might have reduced oxygen, saturations, reduced breath sounds or cause crackles and dullness. If there's pulmonary edema circulation, they might have hypovolemic signs. We've discussed these over earlier. They might have volume overload signs. They may have arrhythmias picked up on ec gs pericarditis or sort of a pericardial rub, you might be able to hear and disability. So they might have confusion and seizures if they were very encephalopathic. So the temperature might be increased. If they were also septic, there may be signs of edema, sort of swelling, rashes, uveitis, and joint swelling. If you were sort of expecting like a rheumatological cause of the kidney injury, you might be able to find a source of infection uh in sepsis, what might we expect? So, in airways, they might be maintaining their own airway. That would be great if that was true. But it also they may be struggling if the G CS was sort of severely decreased breathing. So, respiratory rate might be increased. Oxygen sats may be decreased, may have crackles if you are sort of suspecting like a pneumonia or chest source of infection. Go on. Think about what we might see uh on circulation in a septic patient, considering what we're measuring. Yeah, hypertensive, very good. So their BP is probably gonna be a bit low. Their um capillary refill time will be prolonged. Their heart rate may be increased. They might be tachycardic and their urine output might be reduced. So, disability, we might find their G CS is decreased, their blood sugars might be sort of quite variable. Often happens when people are very unwell and the temperature may be raised because they might be febrile considering they've got an infection. So, exposure, relocating the source of infection and sepsis. Is there a rash? Is there an abscess? Can we see what the catheter is like or any lines, any wounds or sort of purpura that we might see in D IC sepsis? Six we've already talked about. But just important to mention at the bottom here. Finally, uh upper gi bleed to what might we see? So, maybe obstructed at the airway. If there was sort of vomiting or blood, we might even be able to hear sort of gurgling in this situation, you might think about suctioning. So, breathing oxygen saturations might be decreased if they've had significant blood loss or they've aspirated that blood at all. Can anyone think about what we might find in circulation in an upper gi bleed? So it's actually quite similar to what we'd see in sepsis with the fact that they'd be tachycardic, hypotensive might have an increased pilary refill time. They might be pale or cold or flamy. So you need to get IV access so you can deliver fluids and blood disability. The G CSE uh G CS sorry, may decrease the blood sugars variable again. And if there's significant blood loss, their temperature will actually drop. And in the exposure, you're thinking about your abdominal exam, you will do a DRE here and you might find signs of melena or there may be signs of sort of liver disease on the abdominal examination which might point you towards your cause. You might see jaundice, ascites, spider nevi and medusa. Um, ok. Also got a prescribing task. If we've got the time anyone can have a go, I'll let you read it and then you can put an answer in the chat or I can tell you. Yeah, very good gift. Exactly. Um, there's one little caveat to that. So it is 500 mils of Saline naught 0.9% over 15 minutes. For actually a lot of the prescribing exams, you have to write less than 15 minutes. So, if you're given 15 minutes, they actually mark you incorrectly as long as it's anything less than 15 minutes. But yeah, it's 500 miles of Saline over less than 15 minutes. Ok. Thank you very much. Please. Um, give us feedback and stay for the OSC practice it. Is really helpful. Thank you, Isaac. Um Yeah, so I've put, I've put the um feedback in the chat and the QR codes on the screen as well. Um And so we'll be going into our into breakout rooms. So there's two breakout rooms there. So whoever is everyone here staying for osteopor then, so if Adrian gift Janella Julian, do you guys wanna go to Lauren breakout room and then Meg Mohammed Paul Samia and tax Paul, you wanna go to Liza's room? Um And then you guys can go through the oy sessions together. Any questions, I'll be in the main stage here and also popping in and out. Hi guys, if you want to um you can join one of the breakout rooms, Megan Toha.